Factors Affecting the Effectiveness of Hospital Incident Command System; Findings from a Systematic Review.

Objective: To examine all aspects affecting the functioning of the system and the most important factors in its assessment through a systematic review during 1990 to 2017. Methods: This systematic review of the current literature study was conducted during July 2017, and all articles, books, guidelines, manuals and dissertations pertaining to the Incident Command System were analyzed. A total of articles and relevant documents were identified and finally these articles, which we found, were analyzed based on the specified indicators. Results: In this research 992 articles and relevant documents were identified and eventually, 48 articles were included and analyzed. The results were categorized into 6 main groups including 65 subgroups and 221 variables: features of hospital incident command system (14 subgroups and 53 variables), strengths of the system (15 subgroups and 70 variables), weaknesses of the system (10 subgroups and 15 variables), factors influencing the system's performance improvement (12 subgroups and 42 variables), factors that reduce the effectiveness of system include 11 subgroups (10 internal factors and 1 external factor) and 22 variables and important factors in assessing system performance (2 sub-groups and 19 variables). Conclusion: According to the results, Evaluating the effectiveness of a hospital accident command system (HICS) in a valid method can improve the efficiency of this system. In this appraisal, hospital managers and health decision-makers should consider principles, characteristics, strengths and weakness of it.


Introduction
T oday, the occurrence of unexpected incidents around the globe affects governments and nations causing a great number of fatalities and significant economic losses. Despite many recent advances, incidents and disasters remain one of the most important concerns of a man's life [1]. Therefore, it is important to pay more attention to the development of plans, principles on natural disaster reduction and their effects, as well as the proper management of disaster risk reduction [2]. Among the many components involved in crisis management, relief and rescue in emergencies, healthcare centers, especially hospitals, play a major role [3]. Due to the lack of predetermined structures for proper management and focus on activities and training programs, these healthcare centers may expose to multiple risks and performance dysfunction [4]. Therefore, hospital preparedness is the main element of disaster management programs, which should be based on a standard protocol [5]. One of the invaluable management instruments which has an effective role in empowering services of healthcare centers according to global experiences is the Hospital Incident Command system (HICS) [6]. Hospital Incident Command system is a management system used to help manage incidents in unexpected situations and makes an attempt to build a coordination between hospitals and other institutions involved through using a rational and integrated management structure, responsibilities and duty description, creation of transparent reporting channels, and building a simplified and commonplace terminology system [4,7]. Regardless of their size or ability to provide care for the patient, health centers, especially hospitals, can use the system for planning and responding at all-hazard emergency situations [8]. According to the reports published by the organizations in the United States, the system has been able to improve the quality of delivered hospital services in crisis situations very effectively and offered many effective crisis management plan and strategies for the hospital [4]. HICS was designed in 1991 as one of the strategies of hospitals for contrast with disasters with the mission of prevention, mitigation, response, and recovery in hazards [6]. The Hospital Incident Command System (HICS) is widely used by hospitals, yet there is a paucity of research and a lack of developed models to examine HICS implementation [6,9]. In addition, our review shows that there has been no comprehensive study analyzing the positive or negative aspects of the system [9]. Perhaps the importance to develop HICS for emergencies has led scholars to ignore its qualitative aspects [6]. Therefore, in order to improve the effectiveness of Hospital Incident Command System, the current study aimed to assess the effectiveness of system with a focus on its features, strengths, weaknesses, factors contributing to the increasing and decreasing of system effectiveness, as well as important factors involved in system assessment. The aim of the current study was investigating and categorize factors affecting HICS effectiveness with a focus on its features, strengths, weaknesses, factors contributing to the increasing and decreasing of system effectiveness, as well as important factors involved in system assessment to improve the effectiveness of HICS. Therefore, the findings of this study can increase the knowledge of decision makers about the HICS in order to improve hospital readiness and respond appropriately during accidents and disasters.

Data Source
A systematic review was conducted to investigate published studies and documents relating to the factors affecting the performance of Incident Command System. This research was conducted during July 2017. All articles, books, guidelines, manuals and related dissertations were extracted from January 1, 1990 to July 15, 2017. We searched databases including PubMed, Ovid, Springer, Scopus, science of the Web and Google Scholar, Medline for foreign articles, and Iran's Medicine and SID for Persian articles. In addition, we searched ProQuest databases for relevant dissertations. Relevant articles were identified by searching citations and using the snowball mechanism.

Search Strategy
Other than the articles searched using the snowball method, the rest of the articles included in the study was searched using Medical Subject Headings (MeSH) resource: ICS OR "Incident Command Systems" OR "hospital incident command system" OR "hospital emergency incident command system "OR" Incident Command Structure "OR" Incident management framework "AND utilization OR evaluation OR effectiveness OR" Measures of effectiveness "OR performance OR implementation OR assessment OR application OR ORGANIZATION or strengths OR weak points AND" Emergency Operation Center "OR out -of hospital "OR" EOC "OR" Pre hospital "" hospital "OR" Emergency medical system ".

Inclusion Criteria
The inclusion criteria were: articles published in the scientific journals and were relevant to research questions, published in English language and only allocated to Hospital Incident Command System in hospital and pre-hospital settings, Hospital Emergency Operation Center (HEOC) and health centers.

Exclusion Criteria
The exclusion criteria were as follows: published Bull Emerg Trauma 2020;8(2) 64 papers before 1990, published in non-academic journals, not relevant to research questions, not in English and duplicate publications. Further, articles and texts were analyzed using descriptive and thematic approaches. Quality assessment of included studies was done via PRISMA checklist. Figure 1 presents a flow diagram of data collection and its analysis.

Quality Assessment
A 7-question checklist was produced to assess the quality of the retrieved publications by authors (Table 1). The Quality-related questions investigated the following components:1-Number of subgroups mentioned in the main group of hospital incident command system features 2-Number of subgroups mentioned in the main group of strengths of the system, 3-Number of subgroups mentioned in the main group of weaknesses of the system, 4-Number of subgroups mentioned in the main group of factors influencing the system's performance improvement, 5-Number of subgroups mentioned in the main group of factors that reduce the effectiveness of system 6-Number of subgroups mentioned in the main group of variables and important factors in assessing system performance 7-The number of main groups referenced.

Thematic Analysis
In the first step, one researcher analyzed the extracted data of each publication by thematic method (PB), In the second phase, the draft analysis was reviewed by the second researcher (AY), this appraisal continued until two researchers had agreed on themes and subthemes was attained. Any disagreement or mismatch was resolved through discussion and involvement a third researcher (AOT).

Results
A total of 992 articles and documents were searched and finally 52 articles were analyzed based on the specified indicators. The data were analyzed descriptively. Most of the reported citations were related to the United States (59.6), Iran (19.2), China (3.8), Saudi Arabia (3.8) and Australia (3.8). About 92.26% of the articles included in the study published from 2014 to 2017 and 9.51% from 2006 until the end of 2013, concurrent to the fifth and fourth editions, respectively, by the Hospital Incident Command System. An approximately 23% of the articles used either absolute or qualitative approaches and 5.11% were case studies. In addition, the focus of the selected articles ranged from the application of the system in the hospital or pre-hospital system (4.63%), health centers (3.17%), both hospital and health centers (6.7%) and Hospital Emergency Operation Center (HEOC) (7. 5%).Therefore, according to the results, the hospital and pre-hospital settings had the highest rate of system referrals. The abstracts of the relevant articles and documents are shown in Table 2.

Thematic Analysis
The results were categorized into 6 main groups, 65 subgroups and 221 variables as follows: features of hospital incident command system (14 subgroups and 53 variables), strengths of the system (15 subgroups and 70 variables), weaknesses of the system ( 10 subgroups and 15 variables), factors influencing the system's performance improvement (12 subgroups and 42 variables), factors that reduce the effectiveness of system include 11 subgroups (10 internal factors and 1 external factor) and 22 variables and important factors in assessing system performance (2 subgroups and 19 variables) ( Table 3).

Principles and Features Effective in the Success of the Hospital Emergency Hospital System
The hospital incident command system is a management system for controlling, commanding and coordinating the activities of independent groups. This system is designed to achieve the common goal of incident prevention, reduction of mortality, financial losses and severe damage. The system has several features that contribute to achieving these goals and affect its success. The present study indicated that there are several significant features affecting the effectiveness of hospital incident command system including the organized command structure [10] based on the same principles and compliance with the key structure of the incident command [9, 11,12] use of a bureaucratic framework based on military principles [13]. This system is characterized by an organizational form of the structure [6], hierarchical structure [13][14][15], and a specific command chain [16]. In addition, this system provides an appropriate and reliable structure for leadership regardless of the incident type [17]. A clear spoken language -based on the common [4, 6, 9,12-18 ,16], simple and commonplace [4,18] terminology is another feature of the system.the hospital incident command system can define specific organizational functions and roles through job descriptions [11,19,20], rational tenets for the allocation and organization of occupational activities [14] clarify the precise managerial tasks and responsibilities [21], access to a list of personal job descriptions [ [28], responsibilities of hospital incident command system team [29],Specifying specific roles in an organizational table [22,23], and consequently prioritize tasks based on the job description worksheets [6] and recruit the personnel when it becomes necessary [30]. Additionally, numerous studies have focused on other structural features of Hospital Incident Command System including modularity [12], flexibility [13-16, 19, 23, 31], both flexibility and modularity [4, 6-8, 11,14,18,32], analogy and comparison [9], compatibility [17], adaptability in crisis situations at a variety of scales [17,18,23], and category [26,31] and concordance with planned and unplanned events [33] and effective for management in potentially changing environments [10]. The hospital incident command system is based on the principles and characteristics mentioned. Applying these principles and features will ensure the utilization of resources and reduce policy discrepancies and the operations of accountable organizations.

Strengths of System Use
Setting up a precise, efficient and cost-effective managment system is one of the main pillars of disaster management programs in hospitals. The hospital incidnet command system brings significant  benefits to hospitals and plays an important role in improving the quality and delivery of services during emergencies and disasters in hospitals. Hospital incident command system provides a powerful framework [10] standard template [8], structured and organized incident response [16] and facilitates emergency incident response [19]. various advantages for hospital incident command system including provision of the most reliable management protocols [18], and comprehensive crisis management strategy [8] can apply to improve the management capabilities of the emergency [31]. HICS develops strategies for effective and efficient dealing with crisis situations [4], accelerates effective and quick response [8,11], increases effectiveness [18,23], enhances efficiency and effectiveness of the response plan [31,34], facilitates communication between different units of the system in emergency incidents [35], fosters problem solving process among the organizations involved [22,25] and ultimately, reduces the chance of errors and parallel work [25]. Hospital incident command system provides a response planning [36] this system can offer hospital of all sizes with an opportunity to plan, prepare and respond to both emergency and nonemergency situations, make other relevant units and organizations take part in the emergency response depending upon the size and type of incident [4,18], extend or limit the size, scope, and complexity of an incident, assign particular tasks or position based on the magnitude of the incident [8] accelerates effective and quick response [8,11] and consequently guarantees the successful implementation of the plan [37]. Furthermore, numerous studies have mentioned another strength of the system including: detection of system capabilities by other organizations [8], providing a system for coordination [12] coordination between hospitals [4, 23,38] and accountable organizations [4, 6-8, 23], coordinating activities among independent groups and coordinated response actions [6] coordinated response to emergencies situations [8,11,35,39], coordinated multi-disciplinary response to public health threats [28], mutual efforts [40], decentralization in decision-making [10] and building unity in dealing with complex and extreme crises, making incident command system known to the public [7].
Additionally another advantages for hospital incident command system including improvement of administrative communications [8,9], developing a system [12] and communication plan [6], quick and easy communication with other crisis management systems in various rescue and relief departments [4], and facilitated communications [16,24] between hospitals , Medical emergencies and other responsible organizations [12] and foreign organizations [10], clear inter-organizational communication [39], inter-team environmental awareness [41], avoidance of unnecessary communications [26], improved communication [42,43], and existence of effective communication plans [6]. Hospital incident command system with some its features can lead to the cost minimization [4, 18,22,23]: provision of accurate and timely documentation on spending and resource utilization, [11] reduced financial losses and severe injuries, [6] effective use of resources, [22] provision of adequate and efficient medical facilities and personnel [39], effective use of all resources for problem solving [17], provision of resources and equipment [30,44], provision of health care facilities for emergency management [33], use of manpower on a regular basis [45], providing health facilities needed for emergency management [33], regular staffing [45] and sharing resources in organizations and health care centers [6,11]. So considering the strengths of this system, HICS has been identified as one of the factors necessary to boost resilience [42], hospital empowerment [6], incident management and reduced fatalities [6], response to daily operations and emergency and non-emergency situations [22].

Weakness of System Use
According to reports, since the system was initially developed for use in a military and hierarchical structure, it makes hard for the providers of public health system to use the system because of cultural differences [19]. Buck DA and colleagues also stated in their study that although the system was successful in firefighting organizations, it has not been successful in some organizations, such as public health [45]. Similarly, SA Andrew et al. questioned the usefulness capabilities of system in reducing organizational disputes, especially at large-scale incidents and events [46] and FM Burkle et al. found that the system is unable to manage the complexities of a large-scale health-related disaster, especially epidemic situations [47]. the main disadvantage is that the structure cannot be changed or be reliable in terms of training, coordination and administrative capability [48].Furthermore, Timm NL et al. reported that hospital staff were completely unfamiliar with the language system and were unable to use terms such as logistics, operations, financial to explain leadership roles [48].The vastness of the range of job descriptions in the system is another weakness of the system [48] Likewise, NL Timm et al. noted the inefficiency of the system in real time response and exposure to stress [48]. Some studies have also referred to high cost as one of the other problems in the system [23]. R Rimstad's findings suggesting that system sharing between partner organizations is a major problem [13].

Factors Affecting in Increasing Efficiency
Considering the importance of the incident command system in managing and responding effectively to emergencies and disasters, and given the widespread use of this system in hospitals in the world, it is essential to pay attention to factors that increase its efficiency. Therefore, it is important to Bull Emerg Trauma 2020;8(2) 74 pay special attention to several factors for increasing the effectiveness of the system within the hospitals, including familiarity with the organizational structure of the system [18], creation of cluster structures for the system at the planning stage depending on the response phase [47] determining the organizational hierarchy of the structure based on the requirements rather than the titles [17] development of units, positions, description of new duties in accordance with hospital requirements [14] definition of job description and supervision of managers [22] and providing training and information to managers at all levels for creation of a common language and building culture [23]. The application of advanced communication technology to coordinate and provide critical information between incident command teams [41] has been one of the most important elements in improving system performance, furthermore It is necessary to pay special attention to regional coordination plays a significant role in the promotion of system efficiency [49]. Also the existence of transparent reporting channels [7,20,[23][24][25] and transmission of information to high-level authorities [10] are the two main aspects of the incident command system, which can facilitate the information collection, reporting [28], sharing information [31], information acquisition and information dissemination [50]. In order to improve the effectiveness of the system, some additional measures need to be taken: removing financial barriers to implement the system, [23] financing the hospital to establish the system, [23] providing procurement opportunities for staff and offices to strengthen the crisis management culture [15], supporting the Ministry of Health and taking into account additional funding for promotion of system [22].compliance with the rules and regulations [23], compliance with instructions and guidelines among the personnel and medical staff [37], enhancing compliance with the system principles [35] developing guidelines and regulations for hospitals and legal requirements [22].
Taken together, improving the effectiveness of the Hospital Incident Command System depends on understanding and recognizing the features and principles of the system [12,18,23,37], training employees in order to understand the system [9, 23,50], holding continues specialized training courses [9], implementing exercises and procedures [10, 24,41], building an administrative commitment and support for managers [9], creating an interest in the personnel [22], matching the system to the needs, updating and implementing the native version of the system [4, 49] eliminating financial barriers [22,23] and complex and challenging administrative obstacles [22], appointment of competent, experienced and qualified managers [13,22] and understanding the strengths and weaknesses of the system.

Factors Decreasing System Efficiency
In contrast to the above finding, Timm NL et al. showed that while implementing the system, the conflicts from confused job responsibilities and roles can lead to inefficiencies in response and real implementation of the system may be failed [48] and the incompatibility of this system with the management structure of hospitals can decrease the system's effectiveness [49]. YarMohammadinia et al. found that the lack of legal requirements with continuous regulatory change, and the absence of unity of command [23], can weaken and decrease the system's efficiency and effectiveness [23]. Furthermore, the lack of a general method for assessing HICS and hospital-based exercise programs [25], lack of cultural management for crisis command, lack of the need to create this system by managers, lack of support and commitment from authorities and managers, shortage of qualified managers at all levels, paying attention to daily activities by managers, lack of a common management language [23] and lack of senior management commitment to system implementation of the [9] can attenuate system performance.

Points to be Considered in the Organization's Assessment
Assessing the hospital incident management system leads to identifying the weaknesses, strengths, decreasing factors and increasing the efficiency of the system. By identifying these factors and improving them, the efficiency of the incident command system can be improved. The hospital incident command system has been recognized as a vital tool for meeting the compliance with accreditation requirements [8]. The hospital incident command system also provides opportunities for quantitative and targeted structural assessment [51], assessment of hospital preparedness, processes, identifying, locating and recovering errors [41], exercises for preparedness against disasters [51], and finally creates an assessment system [12]. Also, in evaluating the system, all the levels and functions of the system [51], including the administrative and executive support, planning and adaptation, communication, decision-making, exercises, training and retraining [9] in a real or simulated disaster to be quantitatively and accurately analyzed [23]. Assessing the functions of the hospital incident command system is essential and useful, for example, the effectiveness of the coordination function of the system can be assessed by examining the implementation of cross-measures in accordance with the instructions of the mutual interlocutors [35] and reviewing the coordination with local and foreign authorities [9].

Conclusion
Hospital incident command system is one of the References hospital's essential requirements for coping, respond and managing emergencies and disasters. The condition of applying and improving the efficiency of this system is to recognize the principles, characteristics, strengths and weakness of it by hospital staff and managers. It is also necessary to assess and evaluate the performance of the system and its functions with a scientifically valid method. Continuous assessment and recognition of the problems and strengths of the system will improve its efficiency. Therefore, hospital managers and health decision-makers need to plan and done the HICS's assessment, identify its strengths and problems, and train its principles and characteristics for hospital settings.
Conflict of Interest: None declared.